1. Adi Kartolo University of Ottawa

2. Initial Presentation 42-year-old African-American male with type 2 diabetes Chief Complaint: increasing body weight (15 pounds) and increasing fatigue over the past 12 weeks, having hard time walking one flight of stairs or over three blocks to the neighbourhood grocery store.

3. Hx Past medical Hx: 8 mg rosiglitazone and 10 mg clozapine daily Diagnosed with hypertension at the age of 32 Hospitalized with acute psychosis 28 years ago (no recent relapses) A history of schizophrenia and stroke

4. Hx cont’d Family Hx: Father died with end-stage renal disease and sudden cardiac death at age 53 Mother is alive but has diabetes, hypertension and a previous stroke at age 74

5. Hx cont’d Social/Occupational Hx: Short-order cook at a local cafeteria Sedentary lifestyle with no recreational physical activity at all Smokes one pack of cigarettes/day for 31 yrs Doesn’t consume alcohol anymore (heavy alcohol use 12 years prior) No recent history of substance abuse

6. Physical Findings BMI: 32.6 (height 70 inches; weight: 227 lbs) Waist circumference: 42 inches BP: 154/96 mmHg HR: 84 irregular beats/minute RR: 12 breaths/minute Normal body temperature

7. DDx What test should we order? What organs should we check for?

8. More Examination Lungs are clear to auscultation and percussion, no rales or wheezes No focal motor or sensory deficits No tumor or lesion found BP remains at around 154/96 mmHg

9. Blood Test Lipid: Triglycerides = 163 mg/dl (normal: 90-150) Cholesterol= 240 mg/dl (normal: less than 200) HDL = 54 mg/dl (normal: 44 for male; 55 for female) LDL = 153 mg/dl (normal: 130, borderline: 130-159, high risk: 160 and above)

10. Blood Test Cont’d HbA1C = 7.6% (less than 7% is normal; above 9% shows poor control; above 12% shows very poor control) Serum creatinine = 1.1 mg/dl (normal value = 0.8-1.4 mg/dl)

11. Blood Test Cont’d GFR= 95 ml/min/1.73 m 2 Reference table Age (years)Mean eGFR 20-29116 mL/min/1.73 m 2 30-39107 mL/min/1.73 m 2 40-4999 mL/min/1.73 m 2 50-5993 mL/min/1.73 m 2 60-6985 mL/min/1.73 m 2 70+75 mL/min/1.73 m 2

12. Echocardiography E f = 58% (normal range 55-70%) Mitral valve Doppler pattern consistent with mild diastolic dysfunction. Slightly enlarged left ventricle

13. Diagnosis!! ???

14. Diagnosis Hypertensive heart disease (at risk) complicated by diabetes mellitus May have some degree of coronary artery disease At risk for pulmonary edema due to hypertensive heart disease

15. Treatment ???

16. Treatment Referral to a nutritionist for diet program Monitored exercise program Statin therapy Anti-diabetic medication Combination anti-hypertensive therapy